Provider Demographics
NPI:1316118219
Name:SANDOVAL, JOHN PATRICK (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7600
Mailing Address - Country:US
Mailing Address - Phone:505-438-9402
Mailing Address - Fax:
Practice Address - Street 1:720 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7600
Practice Address - Country:US
Practice Address - Phone:505-438-9402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2002-0014363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant